Provider Demographics
NPI:1669027686
Name:KVILVANG, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:KVILVANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 NUTT ST APT 1259
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5392
Mailing Address - Country:US
Mailing Address - Phone:843-861-1309
Mailing Address - Fax:
Practice Address - Street 1:497 OLDE WATERFORD WAY STE 102
Practice Address - Street 2:
Practice Address - City:BELVILLE
Practice Address - State:NC
Practice Address - Zip Code:28451-4183
Practice Address - Country:US
Practice Address - Phone:910-444-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20903225100000X
MTPTP-PT-LIC-17192225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist